Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England.

BACKGROUND: Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes. AIM: To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organizations and describe their views regarding how to improve IVOS. METHODS: An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions. FINDINGS: A total of 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One-third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers. CONCLUSION: Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital.

AIMS: To perform a pharmaco-economic analysis of prescribing alternative antibiotics in patients with a diagnostic label of 'penicillin allergy' and assess whether collation of information from a structured history and liaison with the family physician could reduce costs. METHODS: A prospective pro-forma-based interview of randomly selected in-patients and their family physician was used to assess the validity of the diagnostic label of 'penicillin allergy'. Cost analysis of prescription of alternative antibiotics was performed and compared with first-line agents. RESULTS: 102 patients were assessed and only 40% (n=41) were found to have a history consistent with penicillin hypersensitivity, 40% (n=41) were likely 'not allergic' and 20% (n=20) had 'indeterminate' reactions. Total cost of antibiotics prescribed for patients with penicillin allergy was 1.82-2.58-fold higher than for first-line antibiotics. CONCLUSIONS: Obtaining a structured history from the patient and family physician alone can enable an accurate identification of penicillin allergy status. Total acquisition cost of second-line antibiotics is higher than if these patients were prescribed first-line antibiotics.

Revisiting the accuracy of peak flow meters: a double-blind study using formal methods of agreement.

BACKGROUND: There is widespread use of peak flow meters in both hospitals and general practice. Previous studies to assess peak flow meter accuracy have shown significant differences in the values obtained from different meters. However, many of these studies did not use human subjects for peak flow measurements and did not compare meters of varying usage. In this study human subjects have been used with meters of varying usage. METHODS: Participants were tested using two new (meters A and C) and one old peak flow meter (meter B) in random order. The study was double-blinded. Participants were recruited from the university campus. RESULTS: Four hundred and nine individuals participated. The difference between peak flow means of A and B was -9.93 l/min (95% CI: -12.37 to -7.48, P<0.0001). The difference between peak flow means of B and C was 20.08 l/min (95% CI: 17.85-22.29, P<0.0001). The difference between peak flow means of A and C was 10.15 l/min (95% CI: 7.68-12.61, P<0.0001). CONCLUSION: There was a significant difference between the values obtained from the new and old peak flow meters and also between the two new peak flow meters. We conclude that there is need for caution in interchangeably using flow meters in clinical practice.

The effect of mechanical stress on cartilage energy metabolism.

Cartilage is routinely subjected to varying mechanical stresses which are known to affect matrix turnover by a variety of pathways. Here we show that mechanical loads which suppress sulphate incorporation or protein synthesis by articular chondrocytes, also inhibit rates of oxygen uptake and of lactate production. Although the mechanisms have not been definitively identified, it has been shown that high hydrostatic pressures reduce the activity of the glucose transporter GLUT. Furthermore, fluid expression consequent on static loading changes intracellular pH and ionic strength; intracellular changes which would reduce the activity of glycolytic enzymes. Both pathways would thus lead to a fall in rates of glycolysis and a reduction in intracellular ATP, and - since ATP concentrations directly affect sulphation of proteoglycans - a rapid fall in sulphate incorporation. Our results suggest that load-induced changes in matrix synthesis in cartilage can occur by means other than changes in gene expression.

Regulation of intracellular pH by bovine intervertebral disc cells.

Extracellular acidity is an important determinant of intervertebral disc matrix turnover, possibly exerting effects through changes of intracellular pH (pHi). There is, however, little information concerning the ways in which these cells regulate their pHi. Fluorimetric techniques have been used in the present study to measure pH in isolated intervertebral disc cells, and to characterise the membrane transport pathways by which it is regulated. Nucleus pulposus cells were obtained from bovine intervertebral discs by standard enzymatic digestion techniques, and loaded with the PH-sensitive fluoroprobe BCECF. Resting pHi was approximately 6.7 for cells suspended in either HEPES buffered (HBS) or CO2/HCO3--buffered (BBS) media. Intrinsic buffering capacity was approximately 19 mM pH unit(-1) in HBS and was increased when cells were suspended in BBS. A combination of ion substitution and inhibitor studies for cells at steady-state pH or acidified by exposure to NH4Cl revealed that in HBS Na+ x H+ exchange and an H+-ATPase extrude acid from these cells. Only one of these two systems, the Na+ x H+ exchanger, exhibited a sensitivity to pH, identifying it as the regulator of pH under these conditions. In BBS, an additional pathway which was dependent on extracellular Na+, extracellular HCO3- and intracellular Cl- was detected. These properties are consistent with the four ion HCO3--dependent transporter, although the cation-rich, anion-poor extracellular matrix of the intervertebral disc means that such a pathway has only a marginal role in disc cell pHi regulation.